Rwandan life expectancy doubles in last 20 years, study finds

Country has seen dramatic progress since 1994 genocide that left it one of the world's poorest and sickest nations

Young Rwandan girls wait for the arrival of a small flame of remembrance and to listen to genocide memories at the Petit Seminaire school in Ndera, east of the capital Kigali. Photograph: Ben Curtis/AP

Twenty years after the genocide that killed up to a million and left Rwanda one of the world's poorest and sickest nations, life expectancy in the country has doubled and it is on course to be the first in Africa to meet the UN millennium development goals' health targets.

The paper says: "In the aftermath of one of the worst spasms of mass violence in recorded history, few imagined that Rwanda might one day serve as a model for other nations committed to health equity.

"In 1994, the genocide against the Tutsis led to the deaths of 1 million people in Rwanda (nearly 20% of the population at the time), as well as the displacement of millions more.

"During the 100 days after Easter 1994 a bitter post-colonial divide linked to eugenic constructs of race rooted in a previous century – but grimly familiar to those who remember the crimes of the Nazis – tore the country apart. Whether survivor, perpetrator, or member of the diaspora, no Rwandan emerged unaffected."

The health effects were long lasting. An estimated 250,000 women were raped and many became HIV positive.

A cholera epidemic broke out in refugee camps, fewer than a quarter of children in 1994 were fully vaccinated against measles and polio, the under-five mortality rate was the highest in the world and life expectancy at birth the lowest. Health workers fled and hospitals and clinics were destroyed.

Foreign assistance for health was slow in coming, the authors note. "Many were ready to write Rwanda off as a lost cause." In 1995, the country received $0.50 per person for health, the least of any country in Africa.

Help in dealing with the Aids catastrophe that had hit sub-Saharan Africa was a turning point. The health ministry of Health took the opportunity to scale up treatment of people with HIV in rural areas. Primary healthcare became an integrated system and was built up alongside HIV treatment. Supply chains for Aids drugs were used to deliver all the essential medicines that clinics needed.

The Rwandan constitution enshrined the "right to health" in 2003. Community-based health insurance and performance-based financing have been rolled out. Villages elect three community health workers, trained and equipped with mobile phones to link patients with clinics and hospitals.

"The results of such a health systems approach have been impressive in a country that only 20 years ago lay in ruins," says the paper.

Today 97% of Rwandan infants are vaccinated against 10 diseases, and rates of under-five mortality, maternal mortality, and deaths due to tuberculosis and malaria, have fallen alongside the burden of HIV – although major challenges remain, including tackling the malnutrition of 44.7% of the children.

Farmer, co-founder of Partners in Health, says there are important lessons to be learned. "In the last decade death rates from Aids and tuberculosis have dropped more steeply in Rwanda than just about anywhere, ever.

"In the 30 years that I've been involved in the provision of health-care services to the poor and marginalised, I can think of no more dramatic example of a turnaround than that achieved in Rwanda."